State Form 49883 - Renewal Application For License Approval To Operate A Hospice

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RENEWAL APPLICATION FOR LICENSE
APPROVAL TO OPERATE A HOSPICE
State Form 49883 (R/4-03)
Indiana State Department of Health-Division of Acute Care
Form Approved By State Board Of Accounts-2003
Division of Acute Care Use Only
Date Received__________________
Date Approved__________________ Approved By_______________
All questions on this application must be answered completely and legibly with printed or typed script with supporting documentation attached when
applicable. Incomplete or illegible applications will be returned without being processed.
A non-refundable application fee in the amount of $100.00
must accompany this application. No license or approval shall be issued without receipt of this fee and/or completed application.
Please Type or Print Legibly
SECTION I - FACILITY NAME AND ADDRESS
Facility Name/Address Identification Label
If there are any changes to the name of the facility and/or
address as listed on the Name/Address Identification Label,
please make corrections below. In addition, submit a letter
to this division with the name and/or address changes and
the effective date of these changes. Upon receipt of
correspondence changing the name/address, this division
will send a confirmation letter.
A. Practice Location (facility)
Complete if changes are different from the above identification label
Name of Facility
Street Address
P.O. Box
City
County
Zip Code +4
Telephone Number
Fax Number
Effective date of name change
Effective date of address change
(
)
(
)
SECTION II- MANAGEMENT
If there are any changes in your management, attach a resume, current Indiana applicable license, current criminal history check, and a letter
with the effective date of the staff changes.
Administrator Name
Medical Director Name
Patient Family Care Coordinator Name
SECTION III – OTHER SITES
?
Does the facility have other sites
Yes
No
If yes, please provide the name, address, and telephone number of each site location. (use additional sheet if necessary)
Name
Address (street address/city/zip)
Telephone Number
1

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